Epigenetic programming-The important first 1000 days

Trajectory Patterns of Weight and Length in Children: From Birth Until 2-Years of Age

OBJECTIVE

The aim was to identify trajectory patterns of weight and length in children from birth until two years of life and establish associations with maternal and child characteristics.

METHODS

A mixed-cohort study was conducted in public health services in Colombo-PR, Brazil, between 2018 and 2022. Pregnancy information was gathered through anthropometric data collection and questionnaires. Birth data were extracted from birth record forms, while weight and length data in the first two years of life were obtained from physical and electronic health service records. Weight and length trajectory patterns were identified using a group-based trajectory model. The definition of the number of trajectory patterns to be selected considered the model fit to the type of variable, its practical utility, as well as the probabilities of group membership.

RESULTS

Two trajectory patterns of weight and length were identified among the children. The majority exhibited a pattern of weight (67.8%, n = 382) and length (90.9%, n = 472) considered high and stable, with a tendency to decelerate from one and a half years of age. The probability of belonging to the lower weight gain group was associated with female sex (41.5%, p < 0.001), smoking during pregnancy (48.7%, p = 0.008), prematurity (65.0%, p = 0.001), cesarean delivery (36.4%, p = 0.009), small for gestational age (69.0%, p < 0.001), and twinning (69.2%, p = 0.002). Similarly, the probability of belonging to the lower length gain group was associated with female sex (11.7%, p < 0.001), smoking during pregnancy (20.6%, p = 0.003), cesarean delivery (10.1%, p = 0.048), born small for gestational age (46.4%, p < 0.001), and twinning (46.1%, p < 0.001).

CONCLUSION

Conditions during pregnancy and childbirth can impact growth patterns in the first two years of life.

The association between exposure to famine in early life and risks of diabetic complications in adult patients with type two diabetes

Background

In this study, we aimed to assess the associations between early exposure to famine and the risks of diabetic complications in adult patients with type two diabetes.

Methods

The participants in this study were selected from China National HbA1c Surveillance System (2009-13) and further stratified according to the birth year. The participants born between 1956-59, 1959-61, and 1962-64 were classified as foetal exposed group with 70 852, infant/toddler exposed group with 93 616, and unexposed group with 72 723 participants. The association between exposure to famine in early life and risks of diabetic complications were analysed by logistic regression. We assessed the attributing effects of the interaction between exposure to famine in early life and modifiable risk factors by the multiplicative and additive interactive models.

Results

After adjustments for sex, famine severity, economic status in adulthood, body mass index, blood pressure, low-density lipoprotein cholesterol, glycated haemoglobin, diabetes duration, and the use of antidiabetic agents, the increased risks of coronary heart disease (odds ratio (OR) = 1.31; 95% CI (confidence interval) = 1.26, 1.36), cerebrovascular disease (OR = 1.32; 95% CI = 1.24, 1.41), and diabetic retinopathy (OR = 1.06; 95% CI = 1.02, 1.10) were observed in patients with early-life exposure to famine. The reduced risk of diabetic kidney disease (OR = 0.94; 95% CI = 0.90, 0.99) was observed in patients with early-life exposure to famine compared with those without famine exposure. The interaction analyses indicated that obesity might exacerbate the increased risk of coronary heart disease (OR = 1.26; 95% CI = 1.22, 1.30), cerebrovascular disease (OR = 1.26; 95% CI = 1.21, 1.32), and diabetic retinopathy associated with early-life exposure to famine (OR = 1.09; 95% CI = 1.06, 1.12) in patients with type two diabetes. Moreover, high economic status in adulthood might also exacerbate the increased risk of coronary heart disease (OR = 1.35; 95% CI = 1.30, 1.40) and cerebrovascular disease (OR = 1.33; 95% CI = 1.23, 1.43) associated with early-life exposure to famine in patients with type two diabetes.

Conclusions

Early-life exposure to famine in patients with type two diabetes might be associated with increased risks of coronary heart disease, cerebrovascular disease, and diabetic retinopathy but a reduced risk of diabetic kidney disease in adulthood. Obesity and high economic status might further exacerbate the risk of diabetic complications associated with early-life exposure to famine. Improving early-life nutritional status may promote better risk prevention and management of diabetic complications in patients with type two diabetes.

Real-world insights on nutritional awareness and behaviors among preconception and pregnant women in three Asia Pacific countries

Introduction

In many parts of Asia Pacific (APAC), insufficient intake of micronutrients that are important for conception and pregnancy remains a prevalent issue among women of reproductive age. It is crucial to gain insights into women's nutritional awareness and nutrition-related behaviors, as well as how these relate to their health literacy (HL). This understanding can help identify gaps and guide the development of appropriate intervention strategies. However, there appears to be limited relevant data available for the APAC region. We therefore examined nutritional awareness and behaviors among preconception and pregnant women in three APAC countries, and explored how these were related to women's HL.

Methods

Cross-sectional online surveys were conducted among preconception (i.e., planning to conceive within the next 12 months or currently trying to conceive) and pregnant women in Australia (N = 624), China (N = 600), and Vietnam (N = 300). The survey questionnaire included a validated tool for HL (Newest Vital Sign) and questions to examine awareness and behaviors relating to healthy eating and prenatal supplementation during preconception and pregnancy.

Results

Despite recommendations for a quality diet complemented by appropriate supplementation during preconception and pregnancy, many respondents in each country were not aware of the specific impact of adequate nutrition during these stages. While many respondents reported changes in their diet to eat more healthily during preconception and pregnancy, a substantial proportion were not taking prenatal supplements. Higher HL was related to greater nutritional awareness and higher use of prenatal supplements.

Discussion

Our findings suggest that there are gaps in nutritional awareness and practices of many preconception or pregnant women in the three countries. Interventions to improve HL would be valuable to complement conventional knowledge-centric nutrition education, and enhance understanding and empower women to adopt appropriate nutritional practices throughout their preconception/pregnancy journey.

Impact of Parent Presence and Engagement on Stress in NICU Infants

BACKGROUND

Infants in neonatal intensive care units (NICUs) are exposed to frequent stressors that impact their neurodevelopmental outcomes. Parent presence and engagement are considered critical to improving infant outcomes, yet associations between cumulative NICU parent presence, engagement, and infant stress are infrequently examined.

PURPOSE

To examine associations between NICU infant stress and the amount (hours per week) or frequency (days per week) of parent presence and skin-to-skin care (SSC).

METHODS

A secondary analysis of a data set representing 78 NICU families was conducted. Infant acuity was measured using Neonatal Medical Index (NMI) scores. Parent presence and SSC data were collected from electronic medical records. Infant stress was measured using resting salivary cortisol levels collected at NICU discharge (median = 33 days of life).

RESULTS

More cumulative SSC was associated with lower discharge cortisol in NICU infants for SSC measured in hours per week (P = .03) or days per week (P = .05). Cumulative parent presence was not significantly associated with infant cortisol at discharge. Hierarchical regression analyses examining timing of parent presence supported a model including admission cortisol, NMI score, and parent presence during weeks 1 to 4 of life for explaining infant stress at discharge (R2 = 0.44, P = .004). Analyses examining timing of SSC supported a model including admission cortisol, NMI score, and frequency of SSC during week 1 for explaining infant stress at discharge (R2 = 0.21, P = .04).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Early, frequent SSC to mitigate stress in NICU infants was supported. Results suggested that timing of parent presence impacts NICU infant stress; however, additional study is recommended.

Do women living in a deprived neighborhood have higher maternity care costs and worse pregnancy outcomes? A retrospective population-based study

BACKGROUND

Living in a deprived neighborhood is associated with poorer health, due to factors such as lower socio-economic status and an adverse lifestyle. There is little insight into whether living in deprived neighborhood is associated with adverse maternity care outcomes and maternity health care costs. We expect women in a deprived neighborhood to experience a more complicated pregnancy, with more secondary obstetric care (as opposed to primary midwifery care) and higher maternity care costs. This study aimed to answer the following research question: to what extent are moment of referral from primary to secondary care, mode of delivery, (extreme or very) preterm delivery and maternity care costs associated with neighborhood deprivation?

METHODS

This retrospective cohort study used a national Dutch database with healthcare claims processed by health insurers. All pregnancies that started in 2018 were included. The moment of referral from primary to secondary care, mode of delivery, (extreme or very) preterm delivery and maternity care costs were compared between women in deprived and non-deprived neighborhoods. We reported descriptive statistics, and results of ordinal logistic, multinomial and linear regressions to assess whether differences between the two groups exist.

RESULTS

Women in deprived neighborhoods had higher odds of being referred from primary to secondary care during pregnancy (adjusted OR 1.49, 95%CI 1.41-1.57) and to start their pregnancy in secondary care (adjusted OR 1.55, 95%CI 1.44-1.66). Furthermore, women in deprived neighborhoods had lower odds of assisted delivery than women in non-deprived neighborhoods (adjusted OR 0.73, 95%CI 0.66-0.80), and they had higher odds of a cesarean section (adjusted OR 1.19, 95%CI 1.13-1.25). On average, women in a deprived neighborhood had higher maternity care costs worth 156 euros (95%CI 104-208).

CONCLUSION

This study showed that living in a deprived neighborhood is associated with more intensive maternal care and higher maternal care costs in the Netherlands. These findings support the needs for greater attention to socio-economic factors in maternity care in the Netherlands.

Novel chimeric antigen receptor targets and constructs for acute lymphoblastic leukemia: Moving beyond CD19

Acute lymphoblastic leukemia (ALL) is the second most common acute leukemia in adults with a poor prognosis with relapsed or refractory (R/R) B-cell lineage ALL (B-ALL). Anti-CD19 chimeric antigen receptor (CAR) T-cell therapy has shown excellent response rates in RR B-ALL, but most patients relapse due to poor persistence of CAR T-cell therapy or other tumor-associated escape mechanisms. In addition, anti-CD19 CAR T-cell therapy causes several serious side effects such as cytokine release syndrome and neurotoxicity. In this review, we will discuss novel CAR targets, CAR constructs, and various strategies to boost CARs for the treatment of RR B-ALL. In addition, we discuss a few novel strategies developed to reduce the side effects of CAR.

Setting the research agenda: involving parents in research on children who are HIV-free

INTRODUCTION

There is growing interest in health, developmental and survival outcomes of children who are born HIV-free to women living with HIV (children born HIV-free). To date, the research agenda has been largely determined by researchers, funders and policy makers, with limited involvement of parents, who are key stakeholders. Researchers at UCL Great Ormond Street Institute of Child Health in partnership with community-based organisation 4M Network of Mentor Mothers conducted two workshops with parents in March 2022 to establish research priorities for children born HIV-free, and key considerations for methodological approaches both to research and engagement with the affected communities.

DISCUSSION

When exploring research on children born HIV-free, we consider the following: what aspects of current research are aligned with women and parents' priorities, what is missing and what approaches would be preferred. A holistic approach to research on children born HIV-free should be prioritised, focussing on a breadth of outcomes and how they intersect. Secondary use of existing data sources should be maximised to facilitate this, with a view of monitoring the long-term effects of fetal antiretroviral drug exposure alongside other key health and developmental outcomes. Involving and engaging with parents, and children where possible, must be at the heart of research design to maximise relevance and impact of findings for the affected communities. Potential barriers to engaging with individuals who were children born HIV-free include parental disclosure and individuals not identifying as a child born HIV-free to a mother living with HIV. Stigma-free language must be incorporated into the vocabulary of researchers and other stakeholders, avoiding reference to exposure; we propose the term "children born HIV-free."

CONCLUSIONS

Mothers and parents living with HIV should be involved in research about their children born HIV-free and are key in identifying research priorities so that findings may translate into an impact on their children's health and wellbeing. Meaningful involvement of women living with HIV through trusted community partners is an effective mechanism by which to elicit views on research about their children.

The association between prenatal famine, DNA methylation and mental disorders: a systematic review and meta-analysis

BACKGROUND

Undernutrition in pregnant women is an unfavorable environmental condition that can affect the intrauterine development via epigenetic mechanisms and thus have long-lasting detrimental consequences for the mental health of the offspring later in life. One epigenetic mechanism that has been associated with mental disorders and undernutrition is alterations in DNA methylation. The effect of prenatal undernutrition on the mental health of adult offspring can be analyzed through quasi-experimental studies such as famine studies. The present systematic review and meta-analysis aims to analyze the association between prenatal famine exposure, DNA methylation, and mental disorders in adult offspring. We further investigate whether altered DNA methylation as a result of prenatal famine exposure is prospectively linked to mental disorders.

METHODS

We conducted a systematic search of the databases PubMed and PsycINFO to identify relevant records up to September 2022 on offspring whose mothers experienced famine directly before and/or during pregnancy, examining the impact of prenatal famine exposure on the offspring's DNA methylation and/or mental disorders or symptoms.

RESULTS

The systematic review showed that adults who were prenatally exposed to famine had an increased risk of schizophrenia and depression. Several studies reported an association between prenatal famine exposure and hyper- or hypomethylation of specific genes. The largest number of studies reported differences in DNA methylation of the IGF2 gene. Altered DNA methylation of the DUSP22 gene mediated the association between prenatal famine exposure and schizophrenia in adult offspring. Meta-analysis confirmed the increased risk of schizophrenia following prenatal famine exposure. For DNA methylation, meta-analysis was not suitable due to different microarrays/data processing approaches and/or unavailable data.

CONCLUSION

Prenatal famine exposure is associated with an increased risk of mental disorders and DNA methylation changes. The findings suggest that changes in DNA methylation of genes involved in neuronal, neuroendocrine, and immune processes may be a mechanism that promotes the development of mental disorders such as schizophrenia and depression in adult offspring. Such findings are crucial given that undernutrition has risen worldwide, increasing the risk of famine and thus also of negative effects on mental health.

Indigenous approaches to perinatal mental health: a systematic review with critical interpretive synthesis

Indigenous mothers and birthing parents experience significant inequities during the perinatal period, with mental health distress causing adverse outcomes for mothers/birthing parents and their infants. Limited literature is available to inform our understanding of solutions to these issues, with research primarily focusing on inequities. Our aim was to conduct a systematic review of Indigenous approaches to treatment of perinatal mental health illness. Following the PRISMA guidelines for systematic literature reviews, an electronic search of CINAHL, Medline, PubMed, Embase, APA PsycInfo, OVID Nursing, Scopus, Web of Science, and Google Scholar databases was conducted in January and February 2022 and repeated in June 2022. Twenty-seven studies were included in the final review. A critical interpretive synthesis informed our approach to the systematic review. The work of (Yamane and Helm J Prev 43:167-190, 2022) was drawn upon to differentiate studies and place within a cultural continuum framework. Across the 27 studies, the majority of participants were healthcare workers and other staff. Mothers, birthing parents, and their families were represented in small numbers. Outcomes of interest included a reduction in symptoms, a reduction in high-risk behaviours, and parental engagement/attachment of mothers/birthing parents with their babies. Interventions infrequently reported significant reductions in mental health symptoms, and many included studies focused on qualitative assessments of intervention acceptability or utility. Many studies focused on describing approaches to perinatal mental health distress or considered the perspectives and priorities of families and healthcare workers. More research and evaluation of Indigenous interventions for perinatal mental health illness is required. Future research should be designed to privilege the voices, perspectives, and experiences of Indigenous mothers, birthing parents, and their families. Researchers should ensure that any future studies should arise from the priorities of the Indigenous population being studied and be Indigenous-led and designed.

Abnormal Chromatin Folding in the Molecular Pathogenesis of Epilepsy and Autism Spectrum Disorder: a Meta-synthesis with Systematic Searching

How DNA is folded and packaged in nucleosomes is an essential regulator of gene expression. Abnormal patterns of chromatin folding are implicated in a wide range of diseases and disorders, including epilepsy and autism spectrum disorder (ASD). These disorders are thought to have a shared pathogenesis involving an imbalance in the number of excitatory-inhibitory neurons formed during neurodevelopment; however, the underlying pathological mechanism behind this imbalance is poorly understood. Studies are increasingly implicating abnormal chromatin folding in neural stem cells as one of the candidate pathological mechanisms, but no review has yet attempted to summarise the knowledge in this field. This meta-synthesis is a systematic search of all the articles on epilepsy, ASD, and chromatin folding. Its two main objectives were to determine to what extent abnormal chromatin folding is implicated in the pathogenesis of epilepsy and ASD, and secondly how abnormal chromatin folding leads to pathological disease processes. This search produced 22 relevant articles, which together strongly implicate abnormal chromatin folding in the pathogenesis of epilepsy and ASD. A range of mutations and chromosomal structural abnormalities lead to this effect, including single nucleotide polymorphisms, copy number variants, translocations and mutations in chromatin modifying. However, knowledge is much more limited into how abnormal chromatin organisation subsequently causes pathological disease processes, not yet showing, for example, whether it leads to abnormal excitation-inhibitory neuron imbalance in human brain organoids.

Environmental risk factors in puppies and kittens for developing chronic disorders in adulthood: A call for research on developmental programming

Many dogs and cats are affected by chronic diseases that significantly impact their health and welfare and relationships with humans. Some of these diseases can be challenging to treat, and a better understanding of early-life risk factors for diseases occurring in adulthood is key to improving preventive veterinary care and husbandry practices. This article reviews early-life risk factors for obesity and chronic enteropathy, and for chronic behavioral problems, which can also be intractable with life-changing consequences. Aspects of early life in puppies and kittens that can impact the risk of adult disorders include maternal nutrition, establishment of the gut microbiome, maternal behavior, weaning, nutrition during growth, growth rate, socialization with conspecifics and humans, rehoming and neutering. Despite evidence in some species that the disorders reviewed here reflect the developmental origins of health and disease (DOHaD), developmental programming has rarely been studied in dogs and cats. Priorities and strategies to increase knowledge of early-life risk factors and DOHaD in dogs and cats are discussed. Critical windows of development are proposed: preconception, gestation, the suckling period, early growth pre-neutering or pre-puberty, and growth post-neutering or post-puberty to adult size, the durations of which depend upon species and breed. Challenges to DOHaD research in these species include a large number of breeds with wide genetic and phenotypic variability, and the existence of many mixed-breed individuals. Moreover, difficulties in conducting prospective lifelong cohort studies are exacerbated by discontinuity in pet husbandry between breeders and subsequent owners, and by the dispersed nature of pet ownership.

Milk Exosomal microRNAs: Postnatal Promoters of β Cell Proliferation but Potential Inducers of β Cell De-Differentiation in Adult Life

Pancreatic β cell expansion and functional maturation during the birth-to-weaning period is driven by epigenetic programs primarily triggered by growth factors, hormones, and nutrients provided by human milk. As shown recently, exosomes derived from various origins interact with β cells. This review elucidates the potential role of milk-derived exosomes (MEX) and their microRNAs (miRs) on pancreatic β cell programming during the postnatal period of lactation as well as during continuous cow milk exposure of adult humans to bovine MEX. Mechanistic evidence suggests that MEX miRs stimulate mTORC1/c-MYC-dependent postnatal β cell proliferation and glycolysis, but attenuate β cell differentiation, mitochondrial function, and insulin synthesis and secretion. MEX miR content is negatively affected by maternal obesity, gestational diabetes, psychological stress, caesarean delivery, and is completely absent in infant formula. Weaning-related disappearance of MEX miRs may be the critical event switching β cells from proliferation to TGF-β/AMPK-mediated cell differentiation, whereas continued exposure of adult humans to bovine MEX miRs via intake of pasteurized cow milk may reverse β cell differentiation, promoting β cell de-differentiation. Whereas MEX miR signaling supports postnatal β cell proliferation (diabetes prevention), persistent bovine MEX exposure after the lactation period may de-differentiate β cells back to the postnatal phenotype (diabetes induction).

Epigenetic signature of exposure to maternal Trypanosoma cruzi infection in cord blood cells from uninfected newborns

Aims: To assess the epigenetic effects of in utero exposure to maternal Trypanosoma cruzi infection. Methods: We performed an epigenome-wide association study to compare the DNA methylation patterns of umbilical cord blood cells from uninfected babies from chagasic and uninfected mothers. DNA methylation was measured using Infinium EPIC arrays. Results: We identified a differential DNA methylation signature of fetal exposure to maternal T. cruzi infection, in the absence of parasite transmission, with 12 differentially methylated sites in B cells and CD4⁺ T cells, including eight protein-coding genes. Conclusion: These genes participate in hematopoietic cell differentiation and the immune response and may be involved in immune disorders. They also have been associated with several developmental disorders and syndromes.

Association between severe cyclone events and birth outcomes in Queensland, Australia, 2008-2018: a population based retrospective cohort study

OBJECTIVE

Investigate an association between severe tropical cyclones (TCs) and birth outcomes in an Australian population.

METHODS

We analysed over 600,000 singleton livebirths collected through the Queensland Perinatal Data Collection between 2008 and 2018. We estimated the odds ratios (ORs) of adverse birth outcomes using logistic multi-level modelling.

RESULTS

Exposure to TCs in early pregnancy was associated with significantly higher odds of preterm births in affected compared to unaffected areas during the TC year [OR=1.28, 95%CI=1.11, 1.49, p=0.001] and slightly significant higher odds in affected areas during TC years compared to non-TC years. Significantly higher odds of low birthweight births were associated with mid-pregnancy exposure to cyclone Marcia [OR=1.62, 95%CI=1.00, 2.40, p=0.016] .

CONCLUSIONS

Findings aligned with studies demonstrating an association between exposure to environmental stressors in early to mid-pregnancy and adverse birth outcomes.

IMPLICATIONS FOR PUBLIC HEALTH

There is limited research into TCs and perinatal health in Australia despite most of the population residing along coastlines and TCs presenting one of the nation's most devastating weather events. This study will inform public health practice and contribute to further research into mitigating environmental risks faced by pregnant women.

Using complexity science to understand the role of co-sleeping (bedsharing) in mother-infant co-regulatory processes

Human infants spend most of their time sleeping, but over the first few years of life their sleep becomes regulated to coincide more closely with adult sleep (Galland et al., 2012; Paavonen et al., 2020). Evidence shows that co-sleeping played a role in the evolution of infant sleep regulation, as it is part of an ancient behavioral complex representing the biopsychosocial microenvironment in which human infants co-evolved with their mothers through millions of years of human history (Ball, 2003; McKenna 1986, 1990). This paper is a conceptual, interdisciplinary, integration of the literature on mother-infant co-sleeping and other mother-infant co-regulatory processes from an evolutionary (biological) perspective, using complexity science. Viewing the mother-infant dyad as a "complex adaptive system" (CAS) shows how the CAS fits assumptions of regulatory processes and reveals the role of the CAS in the ontogeny of mother-infant co-regulation of physiological (thermoregulation, breathing, circadian rhythm coordination, nighttime synchrony, and heart rate variability) and socioemotional (attachment and cortisol activity) development.

Epigenetics provides a bridge between early nutrition and long-term health and a target for disease prevention

Exposure to nutritional imbalance during early life can influence disease risk lifelong and across generations. In this long‐term conditioning, epigenetics constitutes a key mechanism. They bridge environmental cues and the expression of genes involved in the setting of long‐standing biological regulations in numerous organs and species. Epigenetic marks are proposed as innovative diagnostic biomarkers and potential targets in the prevention of diseases. However, a number of uncertainties make them difficult to use in clinical approaches in the context of early exposure to nutritional challenge. In conclusion, active investigations in this field are still needed before clinical applications are considered.

Genetically modified mice for research on human diseases: A triumph for Biotechnology or a work in progress?

Genetically modified mice are engineered as models for human diseases. These mouse models include inbred strains, mutants, gene knockouts, gene knockins, and ‘humanized’ mice. Each mouse model is engineered to mimic a specific disease based on a theory of the genetic basis of that disease. For example, to test the amyloid theory of Alzheimer’s disease, mice with amyloid precursor protein genes are engineered, and to test the tau theory, mice with tau genes are engineered. This paper discusses the importance of mouse models in basic research, drug discovery, and translational research, and examines the question of how to define the “best” mouse model of a disease. The critiques of animal models and the caveats in translating the results from animal models to the treatment of human disease are discussed. Since many diseases are heritable, multigenic, age-related and experience-dependent, resulting from multiple gene-gene and gene-environment interactions, it will be essential to develop mouse models that reflect these genetic, epigenetic and environmental factors from a developmental perspective. Such models would provide further insight into disease emergence, progression and the ability to model two-hit and multi-hit theories of disease. The summary examines the biotechnology for creating genetically modified mice which reflect these factors and how they might be used to discover new treatments for complex human diseases such as cancers, neurodevelopmental and neurodegenerative diseases.

The Role of Paternal Involvement on Behavioral Sensitive Responses and Neurobiological Activations in Fathers: A Systematic Review

As fathering research has flourished, a growing body of studies has focused on behavioral and neurobiological mechanisms, respectively associated with caregiving sensitivity and responsiveness to infant stimuli. However, the association between these aspects and the key concept of paternal involvement in childcare (i.e., contribution in infant care in terms of time, availability, and responsibility) has been poorly investigated. The current work aims to systematically review the role of involvement in childcare on both neural activations and sensitive behaviors in fathers by examining (a) how paternal involvement has been measured and (b) whether paternal involvement has been associated with neurobiological activation and behavioral sensitive responses. Inclusion criteria were peer-reviewed quantitative studies, concerning fathers responding to infant stimuli at neurobiological or behavioral level, and including a quantitative measurement of paternal involvement in childcare. A quality rating for each study has been performed based on the measurements adopted to assess paternal involvement. Of 2,529 articles, 27 studies were included. According to our quality rating, 10 out of 27 studies included fairly good-standard measures for measuring paternal involvement, whereas 17 studies used good-standard measures. In addition, 11 studies provided details of paternal involvement in the context of neurobiological responses to infant stimuli, whereas 16 addressed paternal sensitive behaviors. Overall, only 8 studies reported relevant findings about the relationship between paternal involvement and neurobiological responses or sensitive behaviors in fathers. The present study is the first systematically evaluating the scope of paternal involvement in the field of Paternal Brain and fathers' sensitive responsiveness research. When high-standard measures are used, paternal involvement seems to play a significant role in modulating both the hormonal and the neural pathways associated with paternal behaviors. Remarkably, the role of paternal engagement may underpin an adaptive nurturance that is not dependent on pregnancy and childbirth but on caregiving experience. A promising positive link between paternal involvement and behavioral sensitivity may be expected in further studies, which will need to corroborate our conclusion by adopting detailed and appropriate measures assessing paternal involvement. As a future line of research, the inclusion of gay fathers may be beneficial for the field.

Toxic stress, epigenetics and child development

OBJECTIVES

To describe the concept of toxic stress, present the basics of epigenetics and discuss their relationship with child development.

DATA SOURCE

Narrative literature review through a search in the SciELO, Lilacs, Medline databases using the terms Adverse Childhood Experience OR Early Life Stress, Epigenomic OR Epigenetic, Child Development OR Infant Development.

DATA SYNTHESIS

Continuing stress response, known as toxic stress, can occur when a child experiences intense, frequent, and/or prolonged adversity-such as physical or emotional abuse, chronic neglect, for example-without adequate adult support. This toxic stress can have harmful effects on learning, behavior, and health throughout life. Epigenetics, an emerging scientific research area​, shows how environmental influences affect gene expressions and explains how early experiences can impact throughout life.

CONCLUSIONS

Toxic stress causes changes in the human body response systems that can be explained in part by epigenetic changes, which can be temporary or long-lasting. Pediatricians must be aware of these mechanisms and their consequences, seeking to prevent them and thus promote the health, well-being, and quality of life of children, contributing to their full development.

Dynamic and Systemic Perspective in Autism Spectrum Disorders: A Change of Gaze in Research Opens to A New Landscape of Needs and Solutions

The first step for a harmonious bio-psycho-social framework in approaching autism spectrum disorders (ASD) is overcoming the conflict between the biological and the psychosocial perspective. Biological research can provide clues for a correct approach to clinical practice, assuming that it would lead to the conceptualization of a pathogenetic paradigm able to account for epidemiologic and clinical findings. The upward trajectory in ASD prevalence and the systemic involvement of other organs besides the brain suggest that the epigenetic paradigm is the most plausible one. The embryo-fetal period is the crucial window of opportunity for keeping neurodevelopment on the right tracks, suggesting that women's health in pregnancy should be a priority. Maladaptive molecular pathways beginning in utero, in particular, a vicious circle between the immune response, oxidative stress/mitochondrial dysfunction, and dysbiosis-impact neurodevelopment and brain functioning across the lifespan and are the basis for progressive multisystemic disorders that account for the substantial health loss and the increased mortality in ASD. Therefore, the biological complexity of ASD and its implications for health requires the enhancement of clinical skills on these topics, to achieve an effective multi-disciplinary healthcare model. Well-balanced training courses could be a promising starting point to make a change.

Genetics, epigenetics and transgenerational transmission of obesity in children

Sedentary lifestyle and consumption of high-calorie foods have caused a relentless increase of overweight and obesity prevalence at all ages. Its presently epidemic proportion is disquieting due to the tight relationship of obesity with metabolic syndrome and several other comorbidities which do call for urgent workarounds. The usual ineffectiveness of present therapies and failure of prevention campaigns triggered overtime a number of research studies which have unveiled some relevant aspects of obesity genetic and epigenetic inheritable profiles. These findings are revealing extremely precious mainly to serve as a likely extra arrow to allow the clinician's bow to achieve still hitherto unmet preventive goals. Evidence now exists that maternal obesity/overnutrition during pregnancy and lactation convincingly appears associated with several disorders in the offspring independently of the transmission of a purely genetic predisposition. Even the pre-conception direct exposure of either father or mother gametes to environmental factors can reprogram the epigenetic architecture of cells. Such phenomena lie behind the transfer of the obesity susceptibility to future generations through a mechanism of epigenetic inheritance. Moreover, a growing number of studies suggests that several environmental factors such as maternal malnutrition, hypoxia, and exposure to excess hormones and endocrine disruptors during pregnancy and the early postnatal period may play critical roles in programming childhood adipose tissue and obesity. A deeper understanding of how inherited genetics and epigenetics may generate an obesogenic environment at pediatric age might strengthen our knowledge about pathogenetic mechanisms and improve the clinical management of patients. Therefore, in this narrative review, we attempt to provide a general overview of the contribution of heritable genetic and epigenetic patterns to the obesity susceptibility in children, placing a particular emphasis on the mother-child dyad.

Melatonin Levels in Children with Obesity Are Associated with Metabolic Risk and Inflammatory Parameters

Melatonin, the hormone of circadian rhythm regulation, is involved in the modulation of mitochondrial activity through its antioxidant and anti-inflammatory properties. Alteration of circadian rhythms such as sleep is related to obesity and metabolic pathogenesis in adulthood, but studies during childhood are scarce. The present study investigated the association of melatonin with metabolic and inflammatory markers in children with (n = 113) and without obesity (n = 117). Melatonin was measured in saliva four and two hours before bedtime, and after one hour of sleep. Cardiometabolic factors, high sensitivity C-reactive protein, immune markers (monocyte chemoattractant protein-1, plasminogen activator inhibitor-1, tumor necrosis α and interferon-γ), leptin and ghrelin were determined. Sleep duration was recorded by a questionnaire. The melatonin level at 1 h after sleep was found to be increased more than twofold in children with obesity (90.16 (57.16–129.16) pg/mL) compared to controls (29.82 (19.05–61.54) pg/mL, p < 0.001) and was related to fat mass (rho = 0.294, p < 0.001); melatonin levels at 1 h after sleep were inversely correlated with high-density lipoprotein cholesterol. Positive correlation was found with apolipoprotein B, adipokines, high sensitivity C-reactive protein, plasminogen activator inhibitor-1 and tumor necrosis factor-α. Shorter sleep duration and earlier waking times were recorded in children with obesity. In conclusion, melatonin in children with obesity appears to be involved in the global metabolic and inflammatory alteration of this condition.

Building-up fit muscles for the future: Transgenerational programming of skeletal muscle through physical exercise

'Special issue - In Utero and Early Life Programming of Aging and Disease'. Skeletal muscle (SM) adaptations to physical exercise (PE) have been extensively studied due, not only to the relevance of its in situ plasticity, but also to the SM endocrine-like effects in noncontractile tissues, such as brain, liver or adipocytes. Regular PE has been considered a pleiotropic nonpharmacological strategy to prevent and counteract the deleterious consequences of several metabolic, cardiovascular, oncological and neurodegenerative disorders. Additionally, PE performed by parents seems to have a direct impact in the offspring through the transgenerational programming of different tissues, such as SM. In fact, SM offspring programming mechanisms seems to be orchestrated, at least in part, by epigenetic machinery conditioning transcriptional or post-transcriptional processes. Ultimately, PE performed in the early in life is also a critical window of opportunity to positively modulate the juvenile and adult phenotype. Parental PE has a positive impact in several health-related offspring outcomes, such as SM metabolism, differentiation, morphology and ultimately in offspring exercise volition and endurance. Also, early-life PE counteracts conceptional-related adverse effects and induces long-lasting healthy benefits throughout adulthood. Additionally, epigenetics mechanisms seem to play a key role in the PE-induced SM adaptations. Despite the undoubtedly positive role of parental and early-life PE on SM phenotype, a strong research effort is still needed to better understand the mechanisms that positively regulate PE-induced SM programming.

Depression and Anxiety in Mothers Who Were Pregnant During the COVID-19 Outbreak in Northern Italy: The Role of Pandemic-Related Emotional Stress and Perceived Social Support

The COVID-19 pandemic is a collective trauma that is threatening citizens' mental health resulting in increased emotional stress, reduced social support, and heightened risk for affective symptoms. The present study aimed to investigate the effects of antenatal pandemic-related emotional stress and perceived social support on the symptoms of depression and anxiety of mothers who were pregnant during the initial COVID-19 outbreak in northern Italy. A sample of 281 mothers was enrolled at eight maternity units in the first hotspot region of the COVID-19 outbreak in northern Italy. Participants filled out online questionnaires assessing the direct or indirect exposure to the SARS-CoV-2 virus, pandemic-related stress, perceived social support, as well as symptoms of depression and anxiety. Depressive and anxious symptomatology was above clinical concern, respectively, in 26 and 32% of the respondents. Mothers who reported no exposure to SARS-CoV-2 during pregnancy and those who reported at least one direct or indirect exposure did not differ in terms of affective symptoms. Continuous scores and risk for severe depression and anxiety were positively associated with prenatal pandemic-related emotional stress and negatively linked with perceived social support during pregnancy. Women who become mothers during the COVID-19 emergency may be at high risk for affective problems. Dedicated preventive programs are needed to provide adequate preventive support and care for maternal mental health during and after the COVID-19 pandemic.

Epigenetic strategies to boost CAR T cell therapy

Chimeric antigen receptor (CAR) T cell therapy has led to a paradigm shift in cancer immunotherapy, but still several obstacles limit CAR T cell efficacy in cancers. Advances in high-throughput technologies revealed new insights into the role that epigenetic reprogramming plays in T cells. Mechanistic studies as well as comprehensive epigenome maps revealed an important role for epigenetic remodeling in T cell differentiation. These modifications shape the overall immune response through alterations in T cell phenotype and function. Here, we outline how epigenetic modifications in CAR T cells can overcome barriers limiting CAR T cell effectiveness, particularly in immunosuppressive tumor microenvironments. We also offer our perspective on how selected epigenetic modifications can boost CAR T cells to ultimately improve the efficacy of CAR T cell therapy.

Nutritional Strategies for Childhood Obesity Prevention

BACKGROUND

Reducing the spread of obesity represents a challenge for clinicians in which obesity prevention plays a key role in achieving this purpose. The aim of this review is to analyze the nutritional interventions that can be implemented to prevent childhood obesity.

METHODS

Searching PubMed and Cochrane Library between 2019 and 2021. Further searching with no date range for articles selected for their specific relevance in the pediatric area or for their scientific relevance. A total of 871 articles were identified and 90 were included.

RESULTS

We organized the results of the selected articles into age groups, and according to the subjects targeted for interventions or to the site of interventions, reserving an in-depth analysis on specific nutritional aspects. Promotion of breastfeeding, reduction of protein content of formulated milks, and diet of the first 12-24 months, involving family and schools in interventions that promote physical activity and healthy diet, are promising strategies for reduction of the risk of obesity. To increase the efficacy of interventions, a multidimensional approach is crucial.

CONCLUSIONS

A multidimensional approach, which takes into consideration different areas of intervention, is pivotal for childhood obesity prevention. Integrated programs involving several components (nutrition and physical activity at first) at different levels (individual, family, school, and institutional) are crucial.

Characteristics of epigenetic aging across gestational and perinatal tissues

Background

Epigenetic clocks have been used to indicate differences in biological states between individuals of same chronological age. However, so far, only few studies have examined epigenetic aging in newborns—especially regarding different gestational or perinatal tissues. In this study, we investigated which birth- and pregnancy-related variables are most important in predicting gestational epigenetic age acceleration or deceleration (i.e., the deviation between gestational epigenetic age estimated from the DNA methylome and chronological gestational age) in chorionic villus, placenta and cord blood tissues from two independent study cohorts (ITU, n = 639 and PREDO, n = 966). We further characterized the correspondence of epigenetic age deviations between these tissues.

Results

Among the most predictive factors of epigenetic age deviations in single tissues were child sex, birth length, maternal smoking during pregnancy, maternal mental disorders until childbirth, delivery mode and parity. However, the specific factors related to epigenetic age deviation and the direction of association differed across tissues. In individuals with samples available from more than one tissue, relative epigenetic age deviations were not correlated across tissues.

Conclusion

Gestational epigenetic age acceleration or deceleration was not related to more favorable or unfavorable factors in one direction in the investigated tissues, and the relative epigenetic age differed between tissues of the same person. This indicates that epigenetic age deviations associate with distinct, tissue specific, factors during the gestational and perinatal period. Our findings suggest that the epigenetic age of the newborn should be seen as a characteristic of a specific tissue, and less as a general characteristic of the child itself.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01080-y.

How early maternal deprivation changes the brain and behavior?

Early life stress can adversely influence brain development and reprogram brain function and consequently behavior in adult life. Adequate maternal care in early childhood is therefore particularly important for the normal brain development, and adverse early life experiences can lead to altered emotional, behavioral, and neuroendocrine stress responses in the adulthood. As a form of neonatal stress, maternal deprivation/separation is often used in behavioral studies to examine the effects of early life stress and for modeling the development of certain psychiatric disorders and brain pathologies in animal models. The temporary loss of maternal care during the critical postpartum periods remodels the offspring's brain and provokes long-term effects on learning and cognition, the development of mental disorders, aggression, and an increased tendency for the drug abuse. Early life stress through maternal deprivation affects neuroendocrine responses to stress in adolescence and adulthood by dysregulating the hypothalamic-pituitary-adrenal axis and permanently disrupts stress resilience. In this review, we focused on how improper maternal care during early postnatal life affects brain development resulting in modified behavior later in life.

Glucocorticoid receptor gene (NR3C1) methylation during the first thousand days: Environmental exposures and developmental outcomes

The first 1000 days from conception are a sensitive period for human development programming. During this period, environmental exposures may result in long-lasting epigenetic imprints that contribute to future developmental trajectories. The present review reports on the effects of adverse and protective environmental conditions occurring during the first 1000 days on glucocorticoid receptor gene (NR3C1) regulation in humans. Thirty-four studies were included. Wide variations emerged for biological tissues, number and position of analyzed CpG sites, and age at methylation and outcomes assessment. Increased NR3C1 methylation associated with first 1000 days stress exposures. Maternal caregiving behaviors significantly buffered precocious stress exposures. A less robust pattern of findings emerged for the association of NR3C1 methylation with physical health, neurobehavioral and neuroendocrine outcomes. Although drawing comprehensive conclusions is partially hindered by methodological limitations, the present review underlines the relevance of the first 1000 days from conception as a time window for developmental plasticity. Prospective cohort studies and epigenome-wide approaches may increase our understanding of dynamics epigenetic changes and their consequences for child development.

Neonatal Sevoflurane Exposure Impairs Learning and Memory by the Hypermethylation of Hippocampal Synaptic Genes

Sevoflurane anesthesia is widely used in pediatric patients. Clinical studies report memory impairment in those exposed to general anesthesia early in life. DNA methylation is essential for the modulation of synaptic plasticity through regulating the transcription of synaptic genes. Therefore, we tested whether neonatal sevoflurane exposure affects learning and memory underlying the hippocampal DNA methylation of synaptic genes. Male Sprague-Dawley rats were exposed to 3% sevoflurane or air for 2 h daily from postnatal day 7 (P7) to P9. 5-aza-2-deoxycytidine (5-AZA), an inhibitor of DNA methyltransferases (DNMTs), was intraperitoneally injected 30 min before sevoflurane or air exposure on P7-9. The rats were euthanized 6, 12, 24 h, and 28 days after the last sevoflurane exposure, followed by the determination of global and gene-specific DNA methylation. The expression of synaptic proteins and synaptic density and the transcription of Dnmts and ten eleven translocations (Tets) in the hippocampus were measured. The ability of learning and memory was assessed using Morris water maze, novel object recognition, and intruder tests. Repeated neonatal sevoflurane exposure impaired cognitive, social, and spatial memory. The memory impairment was associated with the increased Dnmt1, Dnmt3a, and 5-methylcytosine level and the decreased Tet1 and 5-hydromethylcytosine level. Sevoflurane subsequently induced hypermethylation of Shank2, Psd95, Syn1, and Syp gene and down-regulated the expression of synaptic proteins, which finally led to the decrease of synaptic density in a time-dependent manner. Notably, 5-AZA pretreatment ameliorated learning and memory in sevoflurane-treated rats. In conclusion, neonatal exposure to sevoflurane can impair learning and memory through DNA methylation of synaptic genes.

Autism Spectrum Disorder from the Womb to Adulthood: Suggestions for a Paradigm Shift

The wide spectrum of unique needs and strengths of Autism Spectrum Disorders (ASD) is a challenge for the worldwide healthcare system. With the plethora of information from research, a common thread is required to conceptualize an exhaustive pathogenetic paradigm. The epidemiological and clinical findings in ASD cannot be explained by the traditional linear genetic model, hence the need to move towards a more fluid conception, integrating genetics, environment, and epigenetics as a whole. The embryo-fetal period and the first two years of life (the so-called 'First 1000 Days') are the crucial time window for neurodevelopment. In particular, the interplay and the vicious loop between immune activation, gut dysbiosis, and mitochondrial impairment/oxidative stress significantly affects neurodevelopment during pregnancy and undermines the health of ASD people throughout life. Consequently, the most effective intervention in ASD is expected by primary prevention aimed at pregnancy and at early control of the main effector molecular pathways. We will reason here on a comprehensive and exhaustive pathogenetic paradigm in ASD, viewed not just as a theoretical issue, but as a tool to provide suggestions for effective preventive strategies and personalized, dynamic (from womb to adulthood), systemic, and interdisciplinary healthcare approach.

Measuring the Outcomes of Maternal COVID-19-related Prenatal Exposure (MOM-COPE): study protocol for a multicentric longitudinal project

INTRODUCTION

COVID-19 is a highly infectious respiratory disease that rapidly emerged as an unprecedented epidemic in Europe, with a primary hotspot in Northern Italy during the first months of 2020. Its high infection rate and rapid spread contribute to set the risk for relevant psychological stress in citizens. In this context, mother-infant health is at risk not only because of potential direct exposure to the virus but also due to high levels of stress experienced by mothers from conception to delivery. Prenatal stress exposure associates with less-than-optimal child developmental outcomes, and specific epigenetic mechanisms (eg, DNA methylation) may play a critical role in mediating this programming association.

METHODS AND ANALYSIS

We present the methodological protocol for a longitudinal, multicentric study on the behavioural and epigenetic effects of COVID-19-related prenatal stress in a cohort of mother-infant dyads in Northern Italy. The dyads will be enrolled at 10 facilities in Northern Italy. Saliva samples will be collected at birth to assess the methylation status of specific genes linked with stress regulation in mothers and newborns. Mothers will provide retrospective data on COVID-19-related stress during pregnancy. At 3, 6 and 12 months, mothers will provide data on child behavioural and socioemotional outcomes, their own psychological status (stress, depressive and anxious symptoms) and coping strategies. At 12 months, infants and mothers will be videotaped during semistructured interaction to assess maternal sensitivity and infant's relational functioning.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee (Pavia). Results will be published in peer-reviewed journals and presented at national and international scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04540029; Pre-results.

A global perspective on parental stress in the neonatal intensive care unit: a meta-analytic study

OBJECTIVES

The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) is a well-validated tool to assess different sources of stress in parents during the NICU hospitalization of their infant. The present meta-analytic study assessed the relative impact of different NICU-related sources of parental stress in a pool of studies conducted in a wide set of different countries. Also, differences in stress levels by parent gender and country, as well as the impact of infants' neonatal characteristics and clinical conditions were explored.

METHODS

Records were searched on PubMed, Scopus, and Web of Science (January 1993-December 2019). A purposive open search string was adopted: ["PSS:NICU"] OR ["PSS-NICU"] OR ["Parental Stressor Scale"]. A multiple random-effect meta-analysis was conducted on data from 53 studies extracted by independent coders.

RESULTS

Parental role alteration emerged as the greatest source of stress for both mothers and fathers. Mothers reported higher stress levels compared to fathers. A significant difference emerged only for the subscale related to sights and sounds physical stimuli. No significant effects of infants' neonatal characteristics (gestational age, birth weight) and clinical conditions (comorbidities) emerged. A marginal positive effect of NICU length of stay emerged on the global level of parents' stress.

CONCLUSIONS

The current meta-analysis underlines that parental stress related to NICU admission is a worldwide healthcare issue. Immediate and tailored support to parents after the birth of their at-risk infant should be prioritized to reduce parental stress and to promote mothers and fathers' emotional well-being and new-born neurodevelopmental outcomes.

Epigenetic Programming Through Breast Milk and Its Impact on Milk-Siblings Mating

Background

The epigenetic effects of transmission of certain regulatory molecules, such as miRNAs, through maternal milk on future generations, are still unknown and have not been fully understood yet. We hypothesized that breastfeeding regularly by adoptive-mother may cause transmission of miRNAs as epigenetic regulating factors to the infant, and the marriage of milk-siblings may cause various pathologies in the future generations.

Results

A cross-fostering model using a/a and A^vy/a mice had been established. F2 milk-sibling and F2 control groups were obtained from mating of milk-siblings or unrelated mice. Randomized selected animals in the both F2 groups were sacrificed for miRNA expression studies and the remainings were followed for phenotypic changes (coat color, obesity, hyperglycemia, liver pathology, and life span). The lifespan in the F2 milk-sibling group was shorter than the control group (387 vs 590 days, p = 0.011) and they were more obese during the aging period. Histopathological examination of liver tissues revealed abnormal findings in F2 milk-sibling group. In order to understand the epigenetic mechanisms leading to these phenotypic changes, we analyzed miRNA expression differences between offspring of milk-sibling and control matings and focused on the signaling pathways regulating lifespan and metabolism. Bioinformatic analysis demonstrated that differentially expressed miRNAs were associated with pathways regulating metabolism, survival, and cancer development such as the PI3K-Akt, ErbB, mTOR, and MAPK, insulin signaling pathways. We further analyzed the expression patterns of miR-186-5p, miR-141-3p, miR-345-5p, and miR-34c-5p and their candidate target genes Mapk8, Gsk3b, and Ppargc1a in ovarian and liver tissues.

Conclusion

Our findings support for the first time that the factors modifying the epigenetic mechanisms may be transmitted by breast milk and these epigenetic interactions may be transferred transgenerationally. Results also suggested hereditary epigenetic effects of cross-fostering on future generations and the impact of mother-infant dyad on epigenetic programming.

Immediate parent-infant skin-to-skin study (IPISTOSS): study protocol of a randomised controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological and neurodevelopmental consequences

INTRODUCTION

In Scandinavia, 6% of infants are born preterm, before 37 gestational weeks. Instead of continuing in the in-utero environment, maturation needs to occur in a neonatal unit with support of vital functions, separated from the mother's warmth, nutrition and other benefits. Preterm infants face health and neurodevelopment challenges that may also affect the family and society at large. There is evidence of benefit from immediate and continued skin-to-skin contact (SSC) for term and moderately preterm infants and their parents but there is a knowledge gap on its effect on unstable very preterm infants when initiated immediately after birth.

METHODS AND ANALYSIS

In this ongoing randomised controlled trial from Stavanger, Norway and Stockholm, Sweden, we are studying 150 infants born at 28+0 to 32+6 gestational weeks, randomised to receive care immediately after birth in SSC with a parent or conventionally in an incubator. The primary outcome is cardiorespiratory stability according to the stability of the cardiorespiratory system in the preterm score. Secondary outcomes are autonomic stability, thermal control, infection control, SSC time, breastfeeding and growth, epigenetic profile, microbiome profile, infant behaviour, stress resilience, sleep integrity, cortical maturation, neurodevelopment, mother-infant attachment and attunement, and parent experience and mental health.

ETHICS AND DISSEMINATION

The study has ethical approval from the Swedish Ethical Review Authority (2017/1135-31/3, 2019-03361) and the Norwegian Regional Ethical Committee (2015/889). The study is conducted according to good clinical practice and the Helsinki declaration. The results of the study will increase the knowledge about the mechanisms behind the effects of SSC for very preterm infants by dissemination to the scientific community through articles and at conferences, and to the society through parenting classes and magazines.

STUDY STATUS

Recruiting since April 2018. Expected trial termination June 2021.

TRIAL REGISTRATION NUMBER

NCT03521310 (ClinicalTrials.gov).